Protocol for the Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study in Khulna, Bangladesh: A Prospective cohort to quantify the influence of menstrual health on adolescent girls' health and education outcomes.

BACKGROUND: Menstrual health is essential for gender equity and the well-being of women and girls. Qualitative research has described the burden of poor menstrual health on health and education; however, these impacts have not been quantified, curtailing investment. The Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study aims to describe menstrual health and its trajectories across adolescence, and quantify the relationships between menstrual health and girls' health and education in Khulna, Bangladesh. METHODS AND ANALYSIS: AMEHC is a prospective longitudinal cohort of 2016 adolescent girls recruited at the commencement of class 6 (secondary school, mean age=12) across 101 schools selected through a proportional random sampling approach. Each year, the cohort will be asked to complete a survey capturing (1) girls' menstrual health and experiences, (2) support for menstrual health, and (3) health and education outcomes. Survey questions were refined through qualitative research, cognitive interviews and pilot survey in the year preceding the cohort. Girls' guardians will be surveyed at baseline and wave 2 to capture their perspectives and household demographics. Annual assessments will capture schools' water, sanitation and hygiene, and support for menstruation and collect data on participants' education, including school attendance and performance (in maths, literacy). Cohort enrolment and baseline survey commenced in February 2023. Follow-up waves are scheduled for 2024, 2025 and 2026, with plans for extension. A nested subcohort will follow 406 post-menarche girls at 2-month intervals throughout 2023 (May, August, October) to describe changes across menstrual periods. This protocol outlines a priori hypotheses regarding the impacts of menstrual health to be tested through the cohort. ETHICS AND DISSEMINATION: AMEHC has ethical approval from the Alfred Hospital Ethics Committee (369/22) and BRAC James P Grant School of Public Health Institutional Review Board (IRB-06 July 22-024). Study materials and outputs will be available open access through peer-reviewed publication and study web pages.

Interpersonal Violence and Gender Inequality in Adolescents: A Systematic Analysis of Global Burden of Disease Data From 1990 to 2019.

PURPOSE: Interpersonal violence is a leading cause of adolescent deaths and disability. This study investigates sex differences in burden of interpersonal violence for adolescents and explores associations with gender inequality. METHOD: Using data from the 2019 Global Burden of Disease study, we report numbers, proportions, rates of interpersonal violence deaths and disability adjusted life years (DALYs) for all ages, and rate of change (from 1990 to 2019) in adolescents aged 10-24 years disaggregated by sex and geography. We explored associations with gender inequality using gender inequality index. RESULTS: One in four (24.8%) all-age interpersonal violence deaths are in adolescents. In 2019, the rate of deaths in adolescent males was almost six times higher than females (9.3 vs. 1.6 per 100,000); and since 1990, the rate of decline in DALYs for females was double than that for males (-28.9% vs. -12.7%). By contrast, the burden of sexual violence is disproportionately borne by adolescent females, with over double the rate than males (DALYs: 42.8 vs. 17.5 per 100,000). In countries with greater gender inequality, the male-to-female ratio (deaths and DALYs) was increased among older adolescents, pointing to benefits for males in more gender equal settings. DISCUSSION: Social identities, relationships, and attitudes to violence are established in adolescence, which is an inflection point marking the emergence of disproportionate burdens of interpersonal violence. Our findings affirm that global agendas must be expanded to address interrelated factors driving multiple forms of interpersonal violence experienced by adolescents and reverberating to the next generation.

Changing climates, compounding challenges: a participatory study on how disasters affect the sexual and reproductive health and rights of young people in Fiji.

Pacific youth are at the forefront of the climate crisis, which has important implications for their health and rights. Youth in Fiji currently bear a disproportionate burden of poor experiences and outcomes related to their sexual and reproductive health and rights (SRHR). There is limited information about how the increasing climate impacts may affect their SRHR, and what the implications may be for climate action and disaster risk reduction. We aimed to explore the experiences of 21 Fijian youth in fulfilling their SRHR when living through multiple natural hazards. We conducted 2 workshops and 18 individual semistructured interviews using visual and storytelling methods. Irrespective of the type of hazard or context of disasters, participants identified limited agency as the main challenge that increased SRHR risks. Through reflexive thematic analysis, we identified four themes centred around 'youth SRHR agency'; (1) information and knowledge, (2) community and belonging, (3) needs and resources, and (4) collective risks. These themes encompassed multiple factors that limited youth agency and increased their SRHR risks. Participants highlighted how existing challenges to their SRHR, such as access to SRHR information being controlled by community gatekeepers, and discrimination of sexual and gender diverse youth, were exacerbated in disasters. In disaster contexts, immediate priorities such as water, food and financial insecurity increased risks of transactional early marriage and transactional sex to access these resources. Daily SRHR risks related to normalisation of sexual and gender-based violence and taboos limited youth agency and influenced their perceptions of disasters and SRHR risks. Findings offer important insights into factors that limited youth SRHR agency before, during and after disasters. We underscore the urgency for addressing existing social and health inequities in climate and disaster governance. We highlight four key implications for reducing youth SRHR risks through whole-of-society approaches at multiple (sociocultural, institutional, governance) levels.

Priority Indicators for Adolescent Health Measurement - Recommendations From the Global Action for Measurement of Adolescent Health (GAMA) Advisory Group.

PURPOSE: This article describes the selection of priority indicators for adolescent (10-19 years) health measurement proposed by the Global Action for Measurement of Adolescent health advisory group and partners, building on previous work identifying 33 core measurement areas and mapping 413 indicators across these areas. METHODS: The indicator selection process considered inputs from a broad range of stakeholders through a structured four-step approach: (1) definition of selection criteria and indicator scoring; (2) development of a draft list of indicators with metadata; (3) collection of public feedback through a survey; and (4) review of the feedback and finalization of the indicator list. As a part of the process, measurement gaps were also identified. RESULTS: Fifty-two priority indicators were identified, including 36 core indicators considered to be most important for measuring the health of all adolescents, one alternative indicator for settings where measuring the core indicator is not feasible, and 15 additional indicators for settings where further detail on a topic would add value. Of these indicators, 17 (33%) measure health behaviors and risks, 16 (31%) health outcomes and conditions, eight (15%) health determinants, five (10%) systems performance and interventions, four (8%) policies, programmes, laws, and two (4%) subjective well-being. DISCUSSION: A consensus list of priority indicators with metadata covering the most important health issues for adolescents was developed with structured inputs from a broad range of stakeholders. This list will now be pilot tested to assess the feasibility of indicator data collection to inform global, regional, national, and sub-national monitoring.

Assuring Bangladesh's future: non-communicable disease risk factors among the adolescents and the existing policy responses.

BACKGROUND: The aim of this study is to assess the current status of non-communicable disease (NCD) risk factors amongst adolescents in Bangladesh. We also critically reviewed the existing policy responses to NCD risk among adolescents in Bangladesh. METHODS: This study used a mixed method approach. To quantify the NCD risk burden, we used data from the Global School-based Student Health Survey conducted in Bangladesh. To understand policy response, we reviewed NCD-related policy documents introduced by the Government of Bangladesh between 1971 and 2018 using the WHO recommended NCD Action Plan 2013-2020as study framework. Information from the policy documents was extracted using a matrix, mapping each document against the six objectives of the WHO 2013-2020 Action Plan. RESULTS: Almost all adolescents in Bangladesh had at least one NCD risk factor, and there was a high prevalence of concurrent multiple NCD risk factors; 14% had one NCD risk factor while 22% had two, 29% had three, 34% had four or more NCD risk factors. Out of 38 policy documents, eight (21.1%) were related to research and/or surveys, eight (21.1%) were on established policies, and eleven (29%) were on legislation acts. Three policy documents (7.9%) were related to NCD guidelines and eight (21.1%) were strategic planning which were introduced by the government and non-government agencies/institutes in Bangladesh. CONCLUSIONS: The findings emphasize the needs for strengthening NCD risk factors surveillance and introducing appropriate intervention strategies targeted to adolescents. Despite the Government of Bangladesh introducing several NCD-related policies and programs, the government also needs more focus on clear planning, implementation and monitoring and evaluation approaches to preventing NCD risk factors among the adolescents in Bangladesh.

Monitoring Menstrual Health Knowledge: Awareness of Menstruation at Menarche as an Indicator.

As initiatives to support menstrual health are implemented globally, monitoring progress through a set of comprehensive indicators provides important feedback to direct policies and programs. One proposed core indicator is awareness of menstruation at menarche. That is, at the time of menarche an adolescent girl knowing that menstrual bleeding is something she will experience. In this investigation, we undertook secondary analysis of data collected across four studies to support interpretation of this indicator. We (1) describe the proportion of each sample aware of menstruation at menarche, (2) test variations in awareness according to sociodemographic characteristics, and (3) describe the associations between this indicator and self-reported experience at menarche, social support, and confidence to manage menstruation. Studies included cross-sectional survey data from 421 schoolgirls in Magway, Myanmar, 537 schoolgirls in Soroti, Uganda, 1,359 schoolgirls in Netrokona, Bangladesh, and 599 adult women working in Mukono, Uganda. Awareness of menstruation at menarche varied from 84% in Myanmar to 34% in Bangladesh. Older age at menarche was associated with awareness. Awareness at menarche was not associated with household poverty in the adolescent samples, but greater poverty was associated with lower levels of awareness among adult women. In Myanmar, girls aware of menstruation had significantly higher odds of reporting that they felt prepared (2.85 95% CI 1.34-6.08), happy (OR = 3.81 95% CI 1.74-8.37) and knew what was happening at menarche (OR = 2.37 95% CI 1.34-4.19). However, they also reported higher levels of embarrassment (OR = 1.76 95% CI 1.04-2.97) and did not report significantly less fear (OR = 1.24 95% CI 0.82-1.85). Awareness of menstruation at menarche was associated with higher scores on a menstrual knowledge quiz in both Myanmar (b = 9.51 95% CI 3.99-15.04) and Bangladesh (b = 4.78 95% CI 1.70-7.87). In these studies girls aware of menstruation at menarche also had higher odds of reporting they felt confident discussing menstruation with support sources and managing menstruation at school, while these differences were not significant among schoolgirls in Uganda. Findings support the usefulness of awareness of menstruation at menarche as an indicator to describe minimal knowledge of menstruation and suggest that awareness may signal greater knowledge, social support, and confidence in some settings.

Strengthening assessment and response to mental health needs for Aboriginal and Torres Strait Islander children and adolescents in primary care settings: study protocol for the Ngalaiya Boorai Gabara Budbut implementation project.

INTRODUCTION: Opportunities for improved mental health and wellbeing of Aboriginal and Torres Strait Islander children and young people lie in improving the capability of primary healthcare services to identify mental healthcare needs and respond in timely and appropriate ways. The development of culturally appropriate mental health assessment tools and clinical pathways have been identified as opportunities for strengthening workforce capacity in this area. The Ngalaiya Boorai Gabara Budbut implementation project seeks to pursue these opportunities by developing and validating a psychosocial assessment tool, understanding what services need to better care for your people and developing resources that address those needs. METHODS AND ANALYSIS: The project will be governed by a research governance group comprising Aboriginal service providers, young people, and researchers. It will be implemented in an urban health service in Canberra, and regional services in Moree, Wollongong, and the Illawarra regions of New South Wales Australia. The validation study will follow an argument-based approach, assessing cultural appropriateness and ease of use; test-retest validity; internal consistency, construct validity and the quality of decisions made based on the assessment. Following piloting with a small group of young people and their caregivers (n=10), participants (n=200) will be young people and/or their caregivers, attending one of the partner services. The needs assessment will involve an in-depth exploration of service via an online survey (n=60) and in-depth interviews with service providers (n=16) and young people (n=16). These activities will run concurrently. Service providers, researchers and the governance group will codesign resources that respond to the needs identified and pilot them through the participating services. ETHICS AND DISSEMINATION: The Aboriginal Health and Medical Research Council of NSW Human Research Ethics committee (#1769/21) has approved this project. Informed consent will be obtained from all participants and/or their caregivers (with assent from those aged <16 years) prior to participating in all aspects of the study. Research dissemination will occur through participating health services, academic journal articles and conference presentations.

A call for standardised age-disaggregated health data.

The 2030 Sustainable Development Goals agenda calls for health data to be disaggregated by age. However, age groupings used to record and report health data vary greatly, hindering the harmonisation, comparability, and usefulness of these data, within and across countries. This variability has become especially evident during the COVID-19 pandemic, when there was an urgent need for rapid cross-country analyses of epidemiological patterns by age to direct public health action, but such analyses were limited by the lack of standard age categories. In this Personal View, we propose a recommended set of age groupings to address this issue. These groupings are informed by age-specific patterns of morbidity, mortality, and health risks, and by opportunities for prevention and disease intervention. We recommend age groupings of 5 years for all health data, except for those younger than 5 years, during which time there are rapid biological and physiological changes that justify a finer disaggregation. Although the focus of this Personal View is on the standardisation of the analysis and display of age groups, we also outline the challenges faced in collecting data on exact age, especially for health facilities and surveillance data. The proposed age disaggregation should facilitate targeted, age-specific policies and actions for health care and disease management.

A Scoping Review of Adolescent Health Indicators.

PURPOSE: A host of recent initiatives relating to adolescent health have been accompanied by varying indicator recommendations, with little stakeholder coordination. We assessed currently included adolescent health-related indicators for their measurement focus, identified overlap across initiatives, and determined measurement gaps. METHODS: We conducted a scoping review to map the existing indicator landscape as depicted by major measurement initiatives. We classified indicators as per 33 previously identified core adolescent health measurement areas across five domains and by age groups. We also identified indicators common across measurement initiatives even if differing in details. RESULTS: We identified 413 indicators across 16 measurement initiatives, with most measuring health outcomes and conditions (162 [39%]) and health behaviors and risks (136 [33%]); followed by policies, programs, and laws (49 [12%]); health determinants (44 [11%]); and system performance and interventions (22 [5%]). Age specification was available for 221 (54%) indicators, with 51 (23%) focusing on the full adolescent age range (10-19 years), 1 (<1%) on 10-14 years, 27 (12%) on 15-19 years, and 142 (64%) on a broader age range including adolescents. No definitional information, such as numerator and denominator, was available for 138 indicators. We identified 236 distinct indicators after accounting for overlap. CONCLUSION: The adolescent health measurement landscape is vast and includes substantial variation among indicators purportedly assessing the same concept. Gaps persist in measuring systems performance and interventions; policies, programs, and laws; and younger adolescents' health. Addressing these gaps and harmonizing measurement is fundamental to improve program implementation and accountability for adolescent health globally.

Enablers and barriers to primary healthcare for Aboriginal and Torres Strait Islander adolescents: study protocol for participatory mixed-methods research that builds on WHO global standards.

INTRODUCTION: One-third of Australia's Aboriginal and Torres Strait Islander population are adolescents. Recent data highlight their health needs are substantial and poorly met by existing services. To design effective models of primary healthcare, we need to understand the enablers and barriers to care for Aboriginal and Torres Strait Islander adolescents, the focus of this study. METHODS AND ANALYSIS: This protocol was codesigned with Apunipima Cape York Health Council that supports the delivery of primary healthcare for 11 communities in Far North Queensland. We framed our study around the WHO global standards for high-quality health services for adolescents, adding an additional standard around culturally safe care. The study is participatory and mixed methods in design and builds on the recommended WHO assessment tools. Formative qualitative research with young people and their communities (exploring concepts in the WHO recommended quantitative surveys) seeks to understand demand-side enablers and barriers to care, as well as preferences for an enhanced response. Supply-side enablers and barriers will be explored through: a retrospective audit of clinic data (to identify current reasons for access and what can be strengthened); an objective assessment of the adolescent friendliness of clinical spaces; anonymous feedback from adolescent clients around quality of care received and what can be improved; and surveys and qualitative interviews with health providers to understand their perspectives and needs to provide enhanced care. This codesigned project has been approved by Apunipima Cape York Health Council and Far North Queensland Human Research Ethics Committee. DISSEMINATION AND IMPLICATIONS: The findings from this project will inform a codesigned accessible and responsive model of primary healthcare for Aboriginal and Torres Strait Islander adolescents.

Matching action to need: an analysis of Global Burden of Disease 2017 and population health data to focus adolescent health policy and actions in Myanmar.

Background: Myanmar is a country undergoing rapid transitions in health. Its national strategic policy for young people's health is being revised but there is a paucity of population data to inform local priorities and needs. Objective: In this paper we describe a comprehensive profile of adolescent health in Myanmar to focus policy and health actions. Methods: We used available primary data, and modelled estimates from the GBD 2017, to describe health outcomes (mortality and morbidity), health risks and determinants for adolescents in Myanmar between 1990-2017. A governance group of key stakeholders guided the framing of the study, interpretation of findings, and recommendations. Results: Overall health has improved for adolescents in Myanmar since 1990, however adolescent mortality remains high, particularly so for older adolescent males; all-cause mortality rate for 10-24 years was 70 per 100,000 for females and 149 per 100,000 for males (16,095 adolescent deaths in 2017). Overall, the dominant health problems were injuries for males and non-communicable disease for females in a context of ongoing burden of communicable and nutritional diseases for both sexes, and reproductive health needs for females. Health risks relating to undernutrition (thinness and anaemia) remain prevalent, with other health risks (overweight, binge alcohol use, and substance use) relatively low by global and regional standards but increasing. Gains have been made in social determinants such as adolescent fertility and modern contraception use; however, advances have been more limited in secondary education completion and engagement in employment and post education training. Conclusions: These results highlight the need to focus current efforts on addressing disease and mortality experienced by adolescents in Myanmar, with a specific focus on injury, mental health and non-communicable disease.

Gender inequalities in health and wellbeing across the first two decades of life: an analysis of 40 low-income and middle-income countries in the Asia-Pacific region.

BACKGROUND: By adulthood, gender inequalities in health and wellbeing are apparent. Yet, the timing and nature of gender inequalities during childhood and adolescence are less clear. We describe the emergence of gender inequalities in health and wellbeing across the first two decades of life. METHODS: We focused on the 40 low-income and middle-income countries in Asia and the Pacific. A measurement framework was developed around four key domains of wellbeing across the first two decades: health, education and transition to employment, protection, and a safe environment. Specific measurement constructs were then defined by considering gender indicator frameworks, the Sustainable Development Goals, indicator frameworks for child and adolescent health and wellbeing, and key stakeholder input. Available data were then mapped to define 87 indicators, subsequently populated using databases (UN agencies and the Global Burden of Diseases, Injuries, and Risk Factors Study) and nationally representative surveys. Where possible, estimates in girls were compared with boys to report relative risks. FINDINGS: Although son preference is evident in some settings-as shown by higher than expected male-to-female sex ratios at birth in India, Vietnam, and China (all >1·10 compared with an expected ratio of 1·05) and excess mortality of girl children in some South Asian and Pacific nations-it is during early adolescence where marked gender inequalities consistently emerged. Adolescent girls face considerable disadvantage in relation to sexual and reproductive health (notably in South Asia and the Pacific), with high rates of child marriage (≥30% of women aged 20-24 years married before 18 years in Bangladesh, Nepal, and Afghanistan), fertility (≥65 livebirths per 1000 girls in Nauru, Laos, Afghanistan, Nepal, Marshall Islands, Bangladesh, Vanuatu, and Papua New Guinea), and intimate partner violence (>20% in Timor Leste, Afghanistan, Pakistan, and Myanmar). Despite educational parity in many countries, females aged 15-24 years were less likely than males to be in education, employment, or training in 17 of 19 countries for which data were available. Compared with girls, adolescent boys experienced excess all-cause mortality and substantially higher mortality due to unintentional injury, interpersonal violence, alcohol and other drugs, and suicide, and higher prevalence of harmful drinking and tobacco smoking. INTERPRETATION: These findings call for a focus on gender policy and programming in later childhood and early adolescence before gender inequalities become embedded. FUNDING: UNICEF.

Direct assessment of mental health and metabolic syndrome amongst Indonesian adolescents: a study design for a mixed-methods study sampled from school and community settings.

Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality globally, with the burden largely borne by people living in low- and middle-income countries. Adolescents are central to NCD control through the potential to modify risks and alter the trajectory of these diseases across the life-course. However, an absence of epidemiological data has contributed to the relative exclusion of adolescents from policies and responses. This paper documents the design of a study to measure the burden of metabolic syndrome (a key risk for NCDs) and poor mental health (a key outcome) amongst Indonesian adolescents. Using a mixed-method design, we sampled 16-18-year-old adolescents from schools and community-based settings across Jakarta and South Sulawesi. Initial formative qualitative enquiry used focus group discussions to understand how young people conceptualise mental health and body weight (separately); what they perceive as determinants of these NCDs; and what responses to these NCDs should involve. These findings informed the design of a quantitative survey that adolescents self-completed electronically. Mental health was measured using the Centre for Epidemiologic Studies Depression Scale-Revised (CESD-R) and Kessler-10 (both validated against formal psychiatric interview in a subsample), with the metabolic syndrome measured using biomarkers and anthropometry. The survey also included scales relating to victimisation, connectedness, self-efficacy, body image and quality of life. Adolescents were sampled from schools using a multistage cluster design, and from the community using respondent-driven sampling (RDS). This study will substantially advance the field of NCD measurement amongst adolescents, especially in settings like Indonesia. It demonstrates that high quality, objective measurement is acceptable and feasible, including the collection of biomarkers in a school-based setting. It demonstrates how comparable data can be collected across both in-school and out of school adolescents, allowing a more comprehensive measure of NCD burden, risk and correlates.

'Next Generation Youth Well-being Study:' understanding the health and social well-being trajectories of Australian Aboriginal adolescents aged 10-24 years: study protocol.

INTRODUCTION: Australian Aboriginal and/or Torres Strait Islander (hereafter referred to as 'Aboriginal') adolescents (10-24 years) experience multiple challenges to their health and well-being. However, limited evidence is available on factors influencing their health trajectories. Given the needs of this group, the young age profile of the Aboriginal population and the long-term implications of issues during adolescence, reliable longitudinal data are needed. METHODS AND ANALYSIS: The 'Next Generation: Youth Well-being Study' is a mixed-methods cohort study aiming to recruit 2250 Aboriginal adolescents aged 10-24 years from rural, remote and urban communities in Central Australia, Western Australia and New South Wales. The study assesses overall health and well-being and consists of two phases. During phase 1, we qualitatively explored the meaning of health and well-being for adolescents and accessibility of health services. During phase 2, participants are being recruited into a longitudinal cohort. Recruitment is occurring mainly through community networks and connections. At baseline, participants complete a comprehensive survey and undertake an extensive age relevant clinical assessment. Survey and clinical data will be linked to various databases including those relating to health services; medication; immunisation; hospitalisations and emergency department presentations; death registrations; education; child protection and corrective services. Participants will receive follow-up surveys approximately 2 years after their baseline visit. The 'Next Generation' study will fill important evidence gaps by providing longitudinal data on the health and social well-being of Aboriginal adolescents supplemented with narratives from participants to provide context. ETHICS AND DISSEMINATION: Ethics approvals have been sought and granted. Along with peer-reviewed publications and policy briefs, research findings will be disseminated via reports, booklets and other formats that will be most useful and informative to the participants and community organisations.

Progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990-2016.

BACKGROUND: Rapid demographic, epidemiological, and nutritional transitons have brought a pressing need to track progress in adolescent health. Here, we present country-level estimates of 12 headline indicators from the Lancet Commission on adolescent health and wellbeing, from 1990 to 2016. METHODS: Indicators included those of health outcomes (disability-adjusted life-years [DALYs] due to communicable, maternal, and nutritional diseases; injuries; and non-communicable diseases); health risks (tobacco smoking, binge drinking, overweight, and anaemia); and social determinants of health (adolescent fertility; completion of secondary education; not in education, employment, or training [NEET]; child marriage; and demand for contraception satisfied with modern methods). We drew data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, International Labour Organisation, household surveys, and the Barro-Lee education dataset. FINDINGS: From 1990 to 2016, remarkable shifts in adolescent health occurred. A decrease in disease burden in many countries has been offset by population growth in countries with the poorest adolescent health profiles. Compared with 1990, an additional 250 million adolescents were living in multi-burden countries in 2016, where they face a heavy and complex burden of disease. The rapidity of nutritional transition is evident from the 324·1 million (18%) of 1·8 billion adolescents globally who were overweight or obese in 2016, an increase of 176·9 million compared with 1990, and the 430·7 million (24%) who had anaemia in 2016, an increase of 74·2 million compared with 1990. Child marriage remains common, with an estimated 66 million women aged 20-24 years married before age 18 years. Although gender-parity in secondary school completion exists globally, prevalence of NEET remains high for young women in multi-burden countries, suggesting few opportunities to enter the workforce in these settings. INTERPRETATION: Although disease burden has fallen in many settings, demographic shifts have heightened global inequalities. Global disease burden has changed little since 1990 and the prevalence of many adolescent health risks have increased. Health, education, and legal systems have not kept pace with shifting adolescent needs and demographic changes. Gender inequity remains a powerful driver of poor adolescent health in many countries. FUNDING: Australian National Health and Medical Research Council, and the Bill & Melinda Gates Foundation.

Health and wellbeing of Indigenous adolescents in Australia: a systematic synthesis of population data.

BACKGROUND: Indigenous populations have high rates of disease and premature mortality. Most Indigenous communities are young, and adolescence (age 10-24 years) provides great opportunities for population health gain. However, the absence of a comprehensive account of Indigenous adolescents' health has been a barrier to effective policy. We aimed to report a national health profile for Indigenous adolescents in Australia. METHODS: We undertook a systematic synthesis of population data to report the health and wellbeing of Indigenous adolescents in Australia. A reporting framework for Indigenous adolescent health in Australia was defined to measure health outcomes, health risks, and sociocultural determinants. Available data (primary data from national surveys and administrative datasets, and available published data) were mapped against the defined reporting framework, and the quality graded, with the highest quality data selected to report a health profile for Indigenous adolescents. Comparison with non-Indigenous adolescents was made where possible, and estimates (disaggregated by age, sex, and remoteness) were reported as relative risks. A national advisory group (six Indigenous young people, three Indigenous adult community members, three researchers, three policy makers, and two service providers, all aged ≥16 years) provided input about the reporting framework, interpretation of findings, and policy recommendations. FINDINGS: Data were available for 184 (79%) of 234 elements of the reporting framework. All-cause mortality for Indigenous adolescents (70 per 100 000) was more than twice that of non-Indigenous adolescents, with about 60% of deaths due to intentional self-harm and road traffic injury. 80% of all deaths among Indigenous adolescents were considered as potentially avoidable in the current health system. Communicable diseases (particularly sexually transmitted infections) were leading contributors to morbidity. Almost a third of Indigenous adolescents aged 18-24 years reported high levels of psychological distress (twice the non-Indigenous rate). There was an excess burden of mental disorders and substance use, alongside emerging type 2 diabetes and ischaemic heart disease. Additionally, there were excess intentional and unintentional injuries. Many aspects of this health profile differed markedly from that of non-Indigenous adolescents: rates of acute rheumatic fever, pneumococcal infection, gonorrhoea, and type 2 diabetes resulting in admission to hospital were ten times higher; rates of assault and childbirth in those aged 15-19 years were five times higher; whereas rates of eating disorders, melanoma and other skin cancers, and anaphylaxis were significantly lower. Risks for future ill-health were common; 43% of 15-24 year olds were current tobacco smokers and about 45% had high body mass (overweight or obese). Disadvantage across sociocultural health determinants also emerged, particularly around education. INTERPRETATION: Despite Australia's adolescents having one of the best health profiles globally, Indigenous adolescents have largely been left behind. Adequate responses will require intersectoral actions, including a health system responsive to the needs of Indigenous adolescents. Without a specific focus on adolescents, Australia will not redress Indigenous health inequalities. FUNDING: Australia's National Health and Medical Research Council, Sidney Myer Foundation, and the Murdoch Children's Research Institute.